I understand and agree to the following:
- Medication(s) for the management of my medical condition will be provided as long as I follow the rules/terms/conditions of this agreement. Failure to comply will result in the discontinuation of the medication(s) and/or termination from my provider’s care.
- I will use the medication(s) exactly as prescribed by my provider.
- I agree to submit to urine or oral fluid drug screens to detect the use of illegal substances, non-prescribed, and prescribed medications at any time and without 24 hour notice as ordered by my provider. I agree to the associated charges for the drug screens through the third party provider, Millennium Health.
- I will disclose to my provider all other medications I am taking or that are prescribed to me and disclose to any other provider all medications that are prescribed to me from my provider.
- I agree to not obtain any other controlled medication without consulting with my provider. In the event of emergencies, I will notify my provider within 3 business days of any controlled drug I have obtained from urgent care, emergency departments, etc.
- I understand my provider will routinely access the Prescription Monitoring Program (PMP) to confirm controlled prescription medications I have purchased and which pharmacy they were purchased from.
- I am aware these drugs may lead to physical dependence and/or addiction and I will report any adverse side effects I experience from the controlled medication(s) prescribed to me including, but not limited to: drowsiness, unclear thinking, dizziness, slurred speech, and slowed reflexes.
- I agree to keep all scheduled appointments as requested by my provider and understand failure to do so may result in the ordering of a tapering schedule for my controlled medication(s).
For Female Patients only:
- I understand that if I were to become pregnant, I am required to tell my provider immediately and understand this may result in tapering my controlled medications for the safety of the fetus.